21408 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMirNo. 3 n O8
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. J �f O
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRISS: SANITARY NO. APPLICATION SUBMITTAL DATE
b 2 O S 2 w N a ko-ti'e.- ► l5 46
OW ;R'S NAME: PHONE: COMIRACTOR'S NAME: LIC NO:
O "'I NIC CONTROL#
� ..RCHITECr/ENGINEER. IC NO: / O—L. ADDRESS: ❑
CONTACT: - PHONE: BUILDING PERMIT INFO
s e ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED that F:UCONTRACnOR Sderp DECLARATION QTY ELECTRIC PERMIT FEE JOB
1 hereby affirm that I nm ftheBd under provisions of Chapter 9(commencing JOB DESCRIPTION
QccZ00 with Section Division Business and Prolbssionx Code.and mylicense is
00 in full foreeund effect. PERMITISSUANCE RESIDENTIAL:
oFZuu License Class Lie# ❑SFDWL ❑KITCHEN REMODEL
NQR Date Contractor APPLIANCES-RESIDENTIAL . ❑ADDITION ❑PLUMBING RE-PIPE
D On ARCHITECTS DECLARA]'ION PAN 15
❑MULTI-UNIT ❑ IVRAL
Z O�? 1 undcunderstand my plans shall be used as public rccoNMODIFICATION e MODIFICATION
OZ t] UPTO 200 AMPS ❑INTERIOR ❑CfiIMNEY REPAIR
PPJ 1pp'W Licensed Prefesslomd 201.10OOAMPS IMPROVEMENT /�
ay2�
OWNER-BUILDER IamBUILDER mheCoOVER HXOAMPS ❑BATH REMODHLOREPAIR ),pIOLITION
0. 6 I hereby off rtn that 1 R-exempt R DECLARATION the O!a License Low far the / �
LLO 0.V following reason.(Sex:dnn 70315,Business and Profensions Cole:Any city or ennnty SIGNS ELECTRICAL [-]OTHER
C i7 which requires a permit ro tomcod,ala,improve,demolish,or repair any saact.
y� prior to its iauvna.vlso rcquims the applicant for such permiuo file avigned.ammeat SPECIAL CIRCUITNISC.
r{�yy
that he is licensed pnrsmmn¢ulie provision of the Contractor's License Law(Chapter 9
Tai COQ (commencing with Section]00(aof Division]of the Business.ad Prafessiom Ceske)w TEMP.METCR OR mi.EI COMMERCIAL:
Ihot he is exempt Ihercfmm and the basis fm rhe alleged exemption.Any violation of El NEW BLDG/ADDITION El Df7MoLrr10N
LLXl^m{+•
Section 7031.5 by any applicant for vpenm subjects the vp,Iwmt In a civil penalty of POWER DEVICES
F Z Y not mare Nan five hundred dollars(5501. ❑TENANT ❑FOOD SIiRVICE
pO Las owner ofthe property or my employees with wages as their sole compensation, SWIMMING POOL F.LEMRI 2.
pO IMPROVEMENT
GCGC will do the work,and the swcmrc is not intended or awred fcisale(See.)IM4,Business El OTHER
Wand Professions Cale:The Cnnn.tmfa License Law does no,apply m an owner of OUTLETS-SWITCHES-FaT
property who builds or improves thereon,and who does such work himself or through
his own empdyem,provided mal such improvements aro nal mteabol nr Offered far NEW RESIDENTIAL ELECTR S 1'.
sale,If.however,the building or improvement is sold within one yearofcomphnion,me - SQ.FB FLOOR ARBA g/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve torpor.
pave if own. TOTAL. ' D
❑h as owner of the Set.pm,wy,704 am exclusively contracting with licensedTheCennrraaars i-
12,
ceno mm the project(Sec.o an Business and rty who as Code:)The Cnmm.on, Li- III /
seLaw dtxsnot apply mts itha ofpropeny wcensedaraimproves thereogarJ QTY. PLUMBING PERMIT FEB /s/7�s7j
whocontracts forsuch projects with a contmcvmns)licensed pursuannn the Contractor's
License Law. PERMIT ISSUANCE
Lj I oro exempt ander Sec ,B&P C for this mason
gwt r ALTER-DRAIN&VENT WATER(EA)rte ])at, (:111 vr, yAL4AT1orvrvK1
WORKER:SCthyof prpm,Ow DE CLARATION BACK FLOW PROTECTa DP.VICC O®O
1 hereby vtlimm under penalty of fwrjury one of the following declarations;
❑Ihvve and will for
Section
3700 of the antro Code.for the Workers Compen- UNAII�S-PLOOR,ROOF,A121iA,COND' S'DORIES TYPECONSTRUC'GON
workr provided for mi Section 1]D)of the Labor COJe,for the Performance of rhe
work far which this petro is issued. FIXTURES-PER TRAP
❑ 1 have onJ will maintain Worker's Compensation Innurnncc,as required by Section
370 the labor Cal,for the performance of the work for which His permit is issued. GAS-EA.SYSTEM.I INC.4 OUTLETS
OCC.GROUT' APN
orker's Compemation lnsumncc carrier Policy inordinate.inordinate. -
anicr: PI'ocr: lialicy No.; GAS-EA.SYSTEM-OVER 4(PA)
CERTIFICATE OF EXEMPTION I-TON1 WORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTERCEPTOR
or leas.)
(Thissccmion need not be completed if the permit is far one hundred doll..(S I0GREASE TRAP
) BUILDING DIVISION FEES
PLANCHECK FEE
(certify Pnt in the any
of the work for whjeet1. he Wieonnit ken'Cour er.uill SEWER-SAN ITARY-S'IY)I<M EA.200 Fr.
not employ any person in any manner so as m became.abject Io the Workers'Compen- ENERGY PIiE
O z when Laws of Califomia.Dmc WATER HEATER WNENTIELEC1'R
z Q Applicant GRADING FEE
IA NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEM?NI?ATING
a ; become subject India Wmkera Compensation provisions of the Lamar Code,you must SOILS FEE
kkl forthwith comply with such provisions or this Fttmil shall be devoted revoked, WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY _ NEW RESIDENTIAL('LMB. SQ.FT. PAID
U O
I hereby rut that permit i isamaswc,inn len ding agency forth.performance of Date Receipt#
itsF Lme ender's
fm which This permit is issued(Sec,tI19].Co,C.)
O U Lender's Name TOTAL:
Lender's Address 'D)'fAL:
y I certify Nm 1 have rent thisapplication
and coup and nmre that the above information is BUILDING Flili
h correct. ogre to comply with all city and county ordinances and start lows rel.ingm QTY. .MECHANICAL PERMIT FEE
Uz building cousaonion,and hereby authorize representatives of this city nm unwritten the SEISMICFEH.
alnwe-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep hamtlms the City of Cupertino against ELECTRIC FEE
Iivbilaw,jidgmemacasrsand expenses which may inany isayaccmeagaimisaid City ALTER OR ADD TO MECH.
in comn,gace cel granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0 X]CFM) MECHANICAL PEE
SOURCE REGULATIONS,
AIR HANDLING UNIT(OVER IBXXI CFM) CONSTRUCTIONTAX
i tamvaf ApplicaadConlrvcmr - Date EXHAUST HOOD(WIDUCT7 HOUSING MITIGATION FEC
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or rnmre budding menfom sore or handle hazardom mmcdul I IEA[ING UNIT(TO 100.001-U) _
as damned by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Calc,Section 25532(a)] HEATING UNIT(OVER 10,M)BTU)
❑Yes ❑Na•
VENTILATION PAN SINGLE RESID) PAID
Will the applicant or future buildingequipment uratd
DateniInteractions as contaminant,axdc'nedby the BuyArea Air Quality Management BOILHR-COMP(3HPORIOII,(N013T17) Rrecipr X
District^ TOTAL:
❑Yen [:1 NO BOILER-COMP(OVER 10,0000TU)
I have red the hawNous materials AIR CONDITIONER
I5,1553 an under ,1 and rsta d that
Cali- ISSUANCE DATE
toric Health&Safety Code,Seniors,that i 25531 and 25514.1 to understand the
thc Rthe
ant NEW RHSIDEMrIAI.MECH. SQ.FT. '
building does notcurrentlyshwh have a,nam, or it is my rexptmsibdhymnotifytheoecupant
of the rtquimmenls which most be met priono issuance Of.CeniOcam of Qxup.ncy.
+ s Owner or authonuJ.,cut Date TOTAL: ISSUED BY:
OFFICE